Formby GP Services

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection for this service since its registration with CQC. This key question has not been rated as we did not assess all the quality statements relating to this key question.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy and culture. This was based on providing patient-focused care and treatment that is ethical in that it does not recommend unnecessary tests or treatments.

Staff told us there was a positive atmosphere at work and a culture of wanting to provide the best service to people. Staff were confident that they could raise concerns and that they would be appropriately addressed. They said patients spoke positively about the service and feedback we received supported this.

We did not look at Capable, compassionate and inclusive leaders during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

The provider did not always have clear and effective arrangements for identifying, managing, and mitigating risks. The governance arrangements had not identified that action was needed to maintain a safe environment and promote good infection prevention and control.There was not a consistent process for managing test results. Policies and procedures did not give clear guidance about the role and remit of work experience students. The provider could not evidence that staff had the training they needed and were competent to perform all the tasks included in their roles.

Regular team meetings and board meetings were held to discuss the operation of the service. We saw that the agenda included learning from significant events and complaints, outcome of audits, staffing, training and patient liaison.

The provider understood their duty to collaborate and work in partnership so services worked seamlessly for people. They told us how they had established good working relationships with local hospitals and hospices to support patients. There was a process to obtain a patient’s consent to share information with their NHS GP to promote continuity of care. They shared information with the local authority safeguarding team to support people’s welfare.

The provider worked with patients to understand their views of the service. For example, they had set up a patient liaison group to obtain feedback on the operation of the service, what was working well and where improvements could be made. The provider also sought feedback from patients through surveys and reviewed feedback on internet sites. As part of this assessment, we asked people their views about the service provided at Formby GP Services. We received 27 positive responses. People consistently reported feeling valued, listened to and having fast access to treatment.

The staff team told us there were team meetings in which information about the operation of the service and ideas for improvements were encouraged.

The provider had donated first aid kits to a local church.

The provider had a focus on continuous learning and improvement. Following the assessment the provider took steps to address the areas for improvement that CQC had identified.

Audits were carried out to monitor the operation of the service. We reviewed a sample, including an audit of clinical consultations and safeguarding. This identified areas for improvement and how they were to be addressed.

There was a process to identify and learn from significant events. This assessment has identified how records did not always provide sufficient information to confirm actions had been completed. Following the assessment, the provider told us how this had been addressed.